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MedPAC’s Proposed “Reforms” Should Be Tested Before They’re Implemented: CMS’s Hospital Readmissions Reduction Program Is Exhibit A

Dec 6, 2018• 3

By KIP SULLIVAN JD

Egged on by the Medicare Payment Advisory Commission (MedPAC), Congress has imposed multiple pay-for-performance (P4P) schemes on the fee-for-service Medicare program. MedPAC recommended most of these schemes between 2003 and 2008, and Congress subsequently imposed them on Medicare, primarily via the Affordable Care Act (ACA) of 2010 and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

MedPAC’s five-year P4P binge began with the endorsement of the general concept of P4P at all levels – hospital, clinic, and individual physician – in a series of reports to Congress in 2003, 2004, and 2005. This was followed by endorsements of vaguely described iterations of P4P, notably the “accountable care organization” in 2006 [1], punishment of hospitals for “excess” readmissions in 2007 [2], the “medical home” in 2008 and the “bundled payment” in 2008. None of these proposals were backed up by anything resembling evidence.

Congress endorsed all these schemes without asking for evidence or further details. Congress dealt with the vagueness of, and lack of evidence supporting, MedPAC’s proposals simply by ordering CMS to figure out how to make them work. CMS staff added a few more details to these proposals in the regulations they drafted, but the details were petty and arbitrarily adopted (how many primary doctors had to be in an ACO, how many patients had to sit on the advisory committee of a “patient-centered medical home,” how many days had to expire between a discharge and an admission to constitute a “readmission,” etc.).

New rule, new culture

This process – invention of nebulous P4P schemes by MedPAC, unquestioning endorsement by Congress, and clumsy implementation by CMS – is not working. Every one of the proposals listed above has failed to cut costs (with the possible exception of bundled payments for hip and knee replacements) and may be doing more harm than good to patients. These proposals are failing for an obvious reason – MedPAC and Congress subscribe to the belief that health policies do not need to be tested for effectiveness and safety before they are implemented. In their view, mere opinion suffices.

This has to stop. In this two-part essay I argue for a new rule: MedPAC shall not propose, and Congress shall not authorize, any program that has not been shown by rigorously conducted experiments to be effective at lowering cost without harming patients, improving quality, or both. This will require a culture change at MedPAC. Since its formation in 1997, MedPAC has taken the attitude that it does not have to provide any evidence for its proposals, and it does not have think through its proposals in enough detail to be tested. Over the last two decades MedPAC has demonstrated repeatedly that it believes merely opining about a poorly described solution is sufficient to discharge its obligation to Congress, taxpayers, and Medicare enrollees.
Continue reading…

Iowa Race Questions Logic of Significance of Health Policy Debate

Dec 5, 2018

Joe Molloy, health policy, Congressional gridlock

By JOE MOLLOY

According to the Democrats, their success across the country in the midterm elections has largely been due to the party running on healthcare. Indeed, surveys such as the one conducted by Health Research Incorporated indicated that health was the number one concern for voters during the midterms. In the three states where Medicaid expansion was on the ballot, voters were in favor of it. We’ve been wondering about that, so we took a look at how Iowa voted.

It’s one thing for voters to support healthcare on its own. It’s another for an issue to outweigh all others. Did healthcare really beat every other concern a voter thinks about when picking a candidate during the midterms?

Congressional and Statewide Races

Democrats took 3 of the Iowa’s 4 seats, unseating 2 Republican incumbents. They had a sizeable majority of the votes cast, so things looked good for the Democrats. If the theory holds up, the focus the Democrats kept on healthcare throughout the race would pay off. And it would seem it worked, right?

There’s a big problem here. If Democrats had made gains in Iowa because of healthcare issues, we should expect them to have a pretty resounding victory in the gubernatorial race and in the statehouse.

Integrating in Health Care: 6 Tools for Working Across Boundaries

Dec 4, 2018• 4

By REBECCA FOGG

Today’s health care providers face the formidable challenge of delivering better, more affordable and more convenient care in the face of spiraling care costs and an epidemic of chronic disease. But the most innovative among them are making encouraging progress by “integrating”—which in this context means working across traditional boundaries between patients and clinicians, health care specialties, care sites and sectors.

The impulse to do so is shrewd, according to our innovation research in sectors from computer manufacturing to education. We’ve found that when a product isn’t yet good enough to address the needs of a particular customer segment, a company must control the entire product design and production process in order to improve it. This is necessary because in a “not-good-enough” product, unpredictable and complex interdependencies exist between components, so each component’s design depends on that of all the others.

Given this, managers responsible for the individual components must collaborate—or integrate—in order to align components’ design and assembly toward optimal performance. IBM employed an integrated strategy to improve performance of its early mainframe computers, and this enabled the firm to dominate the early computer industry when mainframes weren’t yet meeting customers’ needs.

In health care delivery, such integration is analogous to, but something more than, coordinated care. It means assembling and aligning resources and processes to deliver the right care, in the right place, at the right time. This type of integration is a core aspiration of innovative providers leading hot-spotting and aging-in-place programs, capitated primary care practices, initiatives addressing health-related social needs, and other care models that depart from America’s traditional, episodic, acute-care model. How are they tackling it? They’re leveraging very specific tools to facilitate work across boundaries. Here are six of the most common we uncovered in our research:

Health in 2 Point 00, Episode 60

Dec 4, 2018• 1

Today on Health in 2 Point 00, Jess and I report from a hedgehog cafe in Tokyo. In this episode, Jess asks me about Bright Health’s $200 million raise and the significance of Amazon’s new EMR product. We also talk about Health 2.0 Asia-Japan, which is happening right now (December 4-5) in Tokyo, showing us the health care market outside of the U.S. Look forward to hearing from some great speakers at the conference, including John Bass from Hashed Health on blockchain, Fred Trotter on security, David Ewing Duncan on the new wellness and personalized medicine, and Adam Pellegrini from Fitbit. And, of course, Jess will be interviewing just about everyone—including a hedgehog—about innovation for WTF Health —Matthew Holt

The Reality of Bush I on Health Care and Its Lessons for Today

Dec 3, 2018• 2

By MICHAEL L. MILLENSON

Former President George H.W. Bush may have been every inch the caring individual portrayed in the eulogies of those who knew him, but when it came to health care reform, two words characterized his attitude: Don’t care.

However, compared to Congressional Republicans, Bush was a profile in conservative courage – a lesson with unfortunate parallels to now.

I covered health policy as a reporter for the Chicago Tribune during the Bush years. One strong memory, confirmed by checking original sources, was the presidential debate on Sept. 25, 1988 between Bush and his Democratic challenger, Massachusetts Gov. Michael Dukakis. When Bush was asked what he’d do for the 37 million people without health insurance – about one in seven Americans – he answered that he would “permit people to buy into Medicaid.”

I remember turning from the TV to my wife and saying, “I have no idea what he’s talking about.” Neither, apparently, did anyone else. A Washington Post story that followed, headlined, “Bush’s Mysterious Medicaid Plan” noted that seeking details from the Bush campaign yielded “answers [that] are contradictory.” The story added that “Bush had never publicly mentioned the idea” until the debate.

Why Narratives Do (and Should) Matter in Bioethics

Dec 1, 2018

By FRANK PASQUALE, JD

There is a fascinating recent decision from the Indian Supreme Court on the Shanbaug case, regarding a woman who has been in a persistent vegetative state (PVS) for over 37 years. A petitioner who had written a book on Shanbaug (Pinky Viranai) argued for a withdrawal of life support. Shanbaug had no family to intervene, but hospital staff resisted, and the Court ultimately sid ed with them. While unflinchingly examining the dehumanizing aspects of PVS, the Court offers a remarkable affirmation of the good will of the staff who have taken care of Shanbaug:

[I]t is evident that the KEM Hospital staff right from the Dean, including the present Dean Dr. Sanjay Oak and down to the staff nurses and para-medical staff have been looking after Aruna for 38 years day and night. What they have done is simply marvelous. They feed Aruna, wash her, bathe her, cut her nails, and generally take care of her, and they have been doing this not on a few occasions but day and night, year after year. The whole country must learn the meaning of dedication and sacrifice from the KEM hospital staff. In 38 years Aruna has not developed one bed sore. It is thus obvious that the KEM hospital staff has developed an emotional bonding and attachment to Aruna Shanbaug, and in a sense they are her real family today.

After a scholarly survey of many countries and U.S. states’ laws on withdrawal of life support, the Court concludes:

A decision has to be taken to discontinue life support either by the parents or the spouse or other close relatives, or in the absence of any of them, such a decision can be taken even by a person or a body of persons acting as a next friend. It can also be taken by the doctors attending the patient. However, the decision should be taken bona fide in the best interest of the patient. . . .Continue reading…

Let Them Depend on Charity

Dec 1, 2018

By MERRILL GOOZNER

Conservative economists writing in today’s Wall Street Journal dismiss the notion that the cost of providing medical care for the uninsured is eventually shifted onto those already insured. Citing an Urban Institute study that appeared in 2008 in Health Affairs, they claim the total cost shift is 1.7 percent at most, or $80 a year for the average plan. They also dismiss as flawed a Families USA study that found there was a significant rise in private insurance premiums to cover the cost of the uninsured.

How did the Democratic-controlled Congress that passed health care reform go wrong by accepting this premise?

Congress ignored the $40 billion to $50 billion that is spent annually by charitable organizations and federal, state and local governments to reimburse doctors and hospitals for the cost of caring for the uninsured. These payments, which amount to approximately three-fourths of the cost of such care, mitigate the extent of cost shifting and reduce the magnitude of the hidden tax on private insurance.

A few paragraphs later, they attack the health care reform law for relying on Medicaid to cover about half the uninsured who will receive coverage under the act:

Medicaid payments to doctors and hospitals are so low that the program creates a cost shift of its own. In fact, a long line of academic research shows that low rates of Medicaid reimbursement translate into higher prices for the privately insured.

So patients who pay nothing or almost nothing do not shift costs because the providers — doctors and hospitals, primarily — get mostly reimbursed for that care by charities and the government. Yet discounted payments through Medicaid are made whole by cost shifting to private plans.Continue reading…

It’s Time to Tango: Impatient With Progress on Patient-Physician Partnerships

Dec 1, 2018

By JESSIE GRUMAN, PHD

The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal—a special issue from 1999 that was focused entirely on doctor-patient partnerships. The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: “it’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;” “there are benefits to this change and dangers to maintaining the status quo;” “some doctors and patients resist the change and some embrace it: why?”

Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnerships still so relevant? And second, why did the editor choose this cover image?

I’ve been mulling over these questions for a couple days and I think answer to the second question sheds light on the first. Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:

It takes two to tango. Ever seen one guy doing the tango? Nope. Whatever he’s doing out there on the dance floor, that’s not tango. Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction. When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not. My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and trade-offs of different approaches and tailors her use of drugs, devices and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: to help me live as well as I can for as long as I can.Continue reading…

Looking for Quality in the Wrong Place

Dec 1, 2018

By CHRIS LANGSTON

Last week I attended the first annual meeting of the Long-Term Quality Alliance and listened to Gregg Pawlson (a geriatrician and executive with NCQA) talk about quality measurement. Right now, quality measurement does too little to drive practice towards quality care because it is based only on things that are “feasible,” or easy to measure—like what gets coded on medical bills. Pawlson observed that while feasibility must be one of the watchwords of quality measurement for now, in the near future electronic medical records should allow us to move beyond billing codes to gather real clinical data for more important quality measurement, including key care processes and outcomes.

I sure hope so. Because those who have looked beyond the dim illumination of current billing-based “quality measures” and searched in the darkness where real processes of clinical care can found have found that the situation is grave. The ACOVE (Assessing Care of Vulnerable Elders) process, while laborious, looks at clinical care where it really happens – in offices and charts – rather than in bills and therefore has a better chance of driving meaningful quality improvement. Readers of Health AGEnda know that I am a big fan of this work, begun at RAND by outstanding clinician-researchers including Neil Wenger, David Solomon, David Reuben, and many others. I believe that ACOVE is an example of what we need in elder care: high quality evidence about essential clinical practices that are sensibly related to real health outcomes and show how we could (often easily) do better for older people. ACOVE is a blessing.

One of the leaders of the ACOVE program is Neil Wenger, MD, a faculty member in General Internal Medicine at UCLA and a researcher at RAND who I have cited in my posts. However, in his talk to the Maxwell School of Public Policy at Syracuse University (another treasure I found last fall at GSA), he really outdid himself in delivering one of the most accessible (and provocative) descriptions of this research program I have ever read. He asks, “Do We Want to Measure the Quality of Care for Vulnerable Older People?” Given the lack of attention to the ACOVE work, I understand his frustration.Continue reading…

Tall Buildings

Dec 1, 2018

By KIMBERLY MANNING, MD

Dreading going in there. Know what you will say. Your pain will be a ten out of ten. When I ask, “How are you?” you will say what you always say: “Terrible.” Your face will be a twisted snarl and you’ll cut your eyes so hard at me that I almost bleed. I’ll ask you what can I do for you and your answer won’t be reasonable. Or at least attainable. That’s why I dread going in there.

Your family is tired. I have decided that they are tired because the only alternative explanation to them not coming to see you or see about you or call you or call about you is that they don’t care. I don’t like that explanation so instead I have decided that they are tired.

Tired of the exhausting marathons that you keep running in circles inside of your own mind. Tired of the short-lived glimmers of normalcy that you sometimes offer only to be smacked back into the reality of your never-quiet mind. Tired of fighting you and fighting the bureaucracy of how to get you somewhere safe with virtually zero resources. I know they are tired. Because it’s only been less than two weeks for me. And I’m tired, too.

And so each day I stand before your door on rounds. Secretly wanting to just keep on walking. Shadow boxing in my mind to get over my tired. And over my dread. And over my anger with my hands being tied snugly behind my back and, on some days, your hands being tied snugly down in restraints for your own safety. Your mind a cacophony of voices and poisonous thoughts that win over me and my little bag of internal medicine tricks. I don’t know what to do.

And so on this day, I just start with what my Mama always taught me.

“Good morning.”

“Hello.”

Something is different. Today, no scowl or lancinating eyes. Instead, you reach your hand out towards me. At first I look at it suspiciously, wondering if you intend to grab at me or shoo me away. I see the wrist ties near the rail of your bed from the corner of my eyes. But all you want to do is hold my hand. I am part surprised and part ashamed.

Hold my hand?

Me? I didn’t see that coming. Me? I was all business. There to just listen to your chest leaping with every thump of your dilated and failing heart, to interpret your engorged neck vein pattern, to look into your mouth, to inspect your swollen legs, and to review the orders. And in the midst of it all, to stand there taking your hand slaps and refusal to cooperate while sifting through my brain for a reasonable treatment plan marrying a terrible, end-stage medical problem to a slippery and elusive psychiatric illness. With no money. And no family.

See? I was shadow boxing to be able to do that. Not hold your hand. You catch me off guard. I stop my busy-ness and let you hold it. I wag my finger at myself and say, tsk-tsk. Your patient is sick, Dr. Manning.

But I knew that before I came. Yet still, I felt tired. I feel your trusting palm, resting in my own. I sit beside you on the mattress and envelope it with my other hand. The room falls quiet as our feet dangle off of the edge of the bed facing the Atlanta skyline. I remember in that moment how beautiful it is. Especially from this room.

“Doctor?”

“Yes?”

“You can see the buildings all the way across town from this window.”

“Yeah.”

“The Marriott Marquis. And behind that is Bank of America.”

I look. “You’re right.”

“How did they make such tall buildings?”

I pause for a moment, pondering the answer to that question. I’m not exactly sure. “I think they do it with cranes and big equipment. And people who aren’t afraid of heights.” I smile and for the first time in two weeks, you smile, too.

“I’m afraid of heights.”

“You are?”

Your smile dissipates and your expression grows distant.

“I am afraid. What will become of me? I am so afraid.”

You look at me with eyes so sane that I forget all of the diagnoses that compete with believing them. Your fingers tighten around my own. I feel more ashamed for shadow-boxing and dreading seeing you.

“Doctor?”

“Yes?”

“I’m tired.”

“I know.”

I sit in silence, rubbing your veiny and weathered hand. I’m tired, too. We both breath in synchrony, yours more laborious from fluid, mine affected by growing emotion. I stare out of the window at The Equifax Building, the shiny cylindrical Westin Hotel, and the skycraping Georgia Pacific building. Suddenly my eyes sting and my face feels warm. Because you are trusting me to help. I want to leap from one of those tall buildings with a single bound to save you. But I can’t. Sometimes even when I want to, I can’t.

I’m not sure how they build those buildings. I also don’t know how to save you. My wings are tied and clipped. So are yours.

On this day, I will start by simply holding your hand. And shadow boxing to keep myself from giving up on you.

Kimberly Manning, MD, is an assistant professor in the Department of Medicine at Grady Memorial Hospital in Atlanta. As both a clinician and educator, she teaches pre-clinical medical students and residents and serves as residency program director for the Transitional Year Residency Program. She blogs regularly at Reflections of a Grady Doctor.